Treatment of pain in acutely burned children

Non-pharmacological interventions to reduce procedural needle pain in children (6-12 years): A systematic review

PROBLEM

Children of different age groups frequently undergo painful procedures involving needles, which can be a source of significant discomfort. Regrettably, this aspect of care often receives insufficient attention from healthcare professionals. The existing literature proposes several methodologies for managing procedural pain, with nonpharmacological techniques being particularly promising. These techniques should be adapted to the patient's age, but literature predominantly emphasizes their use with infants. Thus, it is necessary to evaluate their effectiveness in diverse age groups. Consequently, the purpose of this systematic review is to identify non-pharmacological interventions used to prevent needle-related procedural pain in children (age group 6-12 years).

ELIGIBILITY CRITERIA

Primary studies in English language on non-pharmacological interventions in children aged 6-12 years undergoing needle-related procedures found on PubMed, CINAHL and Embase.

SAMPLE

A total of 18 studies were included.

RESULTS

The results indicate the potential application of various non-pharmacological techniques, with distraction methods standing out. These techniques include activities like utilizing cards, watching cartoons, employing virtual reality and playing video games.

CONCLUSIONS

Children's procedural pain represents a significant challenge in treatment plans. Literature offers several approaches, including nonpharmacologic methods, to control this problem. Prioritizing procedural pain management is critical both at clinical and organizational levels to improve the quality of pediatric care.

IMPLICATIONS

These findings offer different options to support clinical practice, holding the potential to enhance the quality of patient care.

Post-traumatic stress disorder in burn patients - A large database analysis

INTRODUCTION

Post-traumatic stress disorder (PTSD) afflicts a significant portion of burn patients. This study aims to analyze the morbidity, prevalence, and treatment of PTSD in the burn population.

METHODS

Using the TriNetX database, we identified burned patients > 18 years of age without (A) or with (B) a PTSD diagnosis. Patients were then stratified by percent of total body surface area (TBSA) burned. Morbidity and mortality was analyzed in each cohort. Prevalence and pharmacologic treatments for PTSD were analyzed from 2002 to 2022.

RESULTS

PTSD incidence increased from 2.4% (n = 2281) in patients with < 10% to 3.1% (n = 542) in 10-30%, 7.4% (n = 285) in 30-59%, and 5.3% (n = 90) in > 60% TBSA burned. In patients with < 60% TBSA burned, PTSD diagnosis increased the risk of depression (p = <0.0003) and anxiety (p = <0.0001). In those with < 30% TBSA burned, PTSD diagnosis also increased risk of insomnia (p = <0.0001) and pruritus (p = 0.0211 for TBSA <10% and 0.0059 for TBSA 10-29%). PTSD diagnosis was associated with a decreased risk of mortality in patients with > 30% TBSA burned (p = 0.0179 for TBSA 30-59% and p = 0.0089 for TBSA >60%). From 2002 to 2022, the prevalence of PTSD in all burn patients was relatively stable between 2.2% and 3.2%. We found an increase in the use of serotonergic agents and prazosin for the treatment of PTSD during this timeframe.

CONCLUSION

PTSD is not uncommon in the burn population, and those with burns and concomitant PTSD have an increased risk of morbidity. Screening and preventative measures to reduce morbidity and early implementation of care in burned patients with PTSD are indicated.

Clinical Hypnosis for Procedural Pain and Distress in Children: A Scoping Review

OBJECTIVE

Pain and distress are common in children undergoing medical procedures, exposing them to acute and chronic biopsychosocial impairments if inadequately treated. Clinical hypnosis has emerged as a potentially beneficial treatment for children's procedural pain and distress due to evidence of effectiveness and potential superiority to other psychological interventions. However, systematic reviews of clinical hypnosis for children's procedural pain and distress have been predominantly conducted in children undergoing oncology and needle procedures and are lacking in broader pediatric contexts. This scoping review maps the evidence of clinical hypnosis for children's procedural pain and distress across broad pediatric contexts while highlighting knowledge gaps and areas requiring further investigation.

METHODS

Published databases (PubMed, Cochrane Library, PsycINFO, Embase, CINAHL, Scopus, and Web of Science) and grey literature were searched in addition to hand-searching reference lists and key journals (up to May 2022). Two independent reviewers screened the titles and abstracts of search results followed by a full-text review against eligibility criteria. Articles were included if they involved a clinical hypnosis intervention comprising an induction followed by therapeutic suggestions for pain and distress in children undergoing medical procedures. This review followed the Arksey and O'Malley (2005) methodology and incorporated additional scoping review recommendations by the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

A total of 38 eligible studies involving 2,205 children were included after 4,775 articles were screened. Research on clinical hypnosis for children's procedural pain and distress was marked by a lack of fidelity measures and qualitative data as well as by inadequate intervention reporting and high attrition rates. Evidence regarding the safety of clinical hypnosis, pain unpleasantness outcomes, factors influencing outcomes, as well as barriers and facilitators to implementing hypnosis and study procedures was also lacking. Clinical hypnosis has potential benefits for children's procedural pain and distress based on evidence of superiority to control conditions and nonpharmacological interventions (e.g., distraction, acupressure) with moderate to large effect sizes as reported in 76% of studies. However, heterogeneous interventions, contexts, study designs, and populations were identified, and the certainty of the evidence was not evaluated.

CONCLUSIONS

The review suggests potential benefits of clinical hypnosis for children's procedural pain and distress and thus provides a precursor for further systematic reviews and trials investigating the effectiveness of clinical hypnosis. The review also indicates the need to further explore the feasibility, acceptability, implementation, and safety of clinical hypnosis in children undergoing painful procedures. Based on the review, researchers implementing clinical hypnosis should adequately report interventions or use treatment manuals, follow recommended research guidelines, and assess the fidelity of intervention delivery to promote replicating and comparing interventions. The review also highlights common methodological shortcomings of published trials to avoid, such as the lack of implementation frameworks, small sample sizes, inadequate reporting of standard care or control conditions, and limited evidence on pain unpleasantness outcomes.

Hypnotherapy for Procedural Pain and Distress in Children: A Scoping Review Protocol

OBJECTIVE

Inadequately treated pain and distress elicited by medical procedures can put children at higher risk of acute and chronic biopsychosocial sequelae. Children can benefit from hypnotherapy, a psychologically tailored intervention, as an adjunct to pharmacological agents to address the multiple components of pain and distress. Despite providing evidence on the effectiveness and potential superiority of hypnotherapy to other psychological interventions, research on hypnotherapy for pediatric procedural pain and distress has been predominantly limited to oncology and needle procedures. Plus, there is a lack of reporting of intervention manuals, factors influencing hypnotic responding, pain unpleasantness outcomes, theoretical frameworks, adverse events, as well as barriers and facilitators to the feasibility of delivering the intervention and study procedures. The proposed review aims to map the range and nature of the evidence on hypnotherapy for procedural pain and distress in children to identify gaps in literature and areas requiring further investigation.

METHODS

This review will follow the Arksey and O'Malley (2005) methodology and incorporate additional scoping review recommendations by the Joanna Briggs Institute and Preferred Reporting Items for Systematic reviews and Meta-Analyses. Relevant studies will be identified through searching published literature databases (PubMed, Cochrane Library, PsycINFO, Embase, CINAHL, Scopus and Web of Science) and grey literature in addition to hand-searching of reference lists and key journals. Two authors will independently screen titles and abstracts of search results followed by full-texts review against eligibility criteria.

CONCLUSION

Findings are anticipated to guide future research and inform the development of tailored hypnotic interventions in children.

Efficacy of Smartphone Active and Passive Virtual Reality Distraction vs Standard Care on Burn Pain Among Pediatric Patients: A Randomized Clinical Trial

IMPORTANCE

It is unknown whether smartphone-based virtual reality (VR) games are effective in reducing pain among pediatric patients in real-world burn clinics.

OBJECTIVE

To evaluate the efficacy of a smartphone VR game on dressing pain among pediatric patients with burns.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included children aged 6 to 17 years who seen in the outpatient clinic of a large American Burn Association-verified pediatric burn center and level I pediatric trauma center between December 30, 2016, and January 23, 2019. Speaking English as their primary language was an inclusion criterion. Intention-to-treat data analyses were conducted from December 2019 to March 2020.

INTERVENTIONS

Active VR participants played a VR game; passive VR participants were immersed in the same VR environment without interactions. Both groups were compared with a standard care group. One researcher administered VR and observed pain while another researcher administered a posttrial survey that measured the child's perceived pain and VR experience. Nurses were asked to report the clinical utility.

MAIN OUTCOMES AND MEASURES

Patients self-reported pain using a visual analog scale (VAS; range, 0-100). A researcher observed patient pain based on the Face, Legs, Activity, Cry, and Consolability-Revised (FLACC-R) scale. Nurses were asked to report VR helpfulness (range, 0-100; higher scores indicate more helpful) and ease of use (range, 0-100; higher scores indicate easier to use).

RESULTS

A total of 90 children (45 [50%] girls, mean age, 11.3 years [95% CI, 10.6-12.0 years]; 51 [57%] White children) participated. Most children had second-degree burns (81 [90%]). Participants in the active VR group had significantly lower reported overall pain (VAS score, 24.9 [95% CI, 12.2-37.6]) compared with participants in the standard care control group (VAS score, 47.1 [95% CI, 32.1-62.2]; P = .02). The active VR group also had a lower worst pain score (VAS score, 27.4 [95% CI, 14.7-40.1]) than both the passive VR group (VAS score, 47.9 [95% CI, 31.8-63.9]; P = .04) and the standard care group (VAS score, 48.8 [95% CI, 31.1-64.4]; P = .03). Simulator sickness scores (range, 0-60; lower scores indicate less sickness) were similar for active VR (19.3 [95% CI, 17.5-21.1]) and passive VR groups (19.5 [95% CI, 17.6-21.5]). Nurses also reported that the VR games could be easily implemented in clinics (helpfulness, active VR: 84.2; 95% CI, 74.5-93.8; passive VR: 76.9; 95% CI, 65.2-88.7; ease of use, active VR: 94.8, 95% CI, 91.8-97.8; passive VR: 96.0, 95% CI, 92.9-99.1).

CONCLUSIONS AND RELEVANCE

In this study, a smartphone VR game was effective in reducing patient self-reported pain during burn dressing changes, suggesting that VR may be an effective method for managing pediatric burn pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04544631.

Nonopioid GTS-21 Mitigates Burn Injury Pain in Rats by Decreasing Spinal Cord Inflammatory Responses

BACKGROUND

Burn injury (BI) pain consists of inflammatory and neuropathic components and activates microglia. Nicotinic alpha 7 acetylcholine receptors (α7AChRs) expressed in microglia exhibit immunomodulatory activity during agonist stimulation. Efficacy of selective α7AChR agonist GTS-21 to mitigate BI pain and spinal pain-mediators was tested.

METHODS

Anesthetized rats after hind-paw BI received intraperitoneal GTS-21 or saline daily. Allodynia and hyperalgesia were tested on BI and contralateral paw for 21 days. Another group after BI receiving GTS-21 or saline had lumbar spinal cord segments harvested (day 7 or 14) to quantify spinal inflammatory-pain transducers or microglia activation using fluorescent marker, ionized calcium-binding adaptor protein (Iba1).

RESULTS

BI significantly decreased allodynia withdrawal threshold from baseline of ~9-10 to ~0.5-1 g, and hyperalgesia latency from ~16-17 to ~5-6 seconds by day 1. Both doses of GTS-21 (4 or 8 mg/kg) mitigated burn-induced allodynia from ~0.5-1 to ~2-3 g threshold (P = .089 and P = .010), and hyperalgesia from ~5-6 to 8-9 seconds (P < .001 and P < .001) by day 1. The GTS-21 group recovered to baseline pain threshold by day 15-17 compared to saline-treated, where the exaggerated nociception persisted beyond 15-17 days. BI significantly (P < .01) increased spinal cord microgliosis (identified by fluorescent Iba1 staining), microglia activation (evidenced by the increased inflammatory cytokine), and pain-transducer (protein and/or messenger RNA [mRNA]) expression (tumor necrosis factor-α [TNF-α], interleukin-1β [IL-1β], nuclear factor-kappa B [NF-κB], interleukin-6 [IL-6], Janus-associated kinase signal transducer and activator of transcription 3 [JAK-STAT3], and/or N-methyl-D-aspartate receptor [NMDAR]). GTS-21 mitigated pain-transducer changes. The α7AChR antagonist methyllycaconitine nullified the beneficial effects of GTS-21 on both increased nociception and pain-biomarker expression.

CONCLUSIONS

Nonopioid, α7AChR agonist GTS-21 elicits antinociceptive effects at least in part by decreased activation spinal-cord pain-inducers. The α7AChR agonist GTS-21 holds promise as potential therapeutic adjunct to decrease BI pain by attenuating both microglia changes and expression of exaggerated pain transducers.

Assessing opioid administration in pediatric burn patients with nonsurgical management

BACKGROUND

Despite the vast literature studying the opioid crisis, sparse data describe this in the pediatric burn population. This study sought to assess patient-level characteristics and their potential effects on opioid administration in nonsurgical pediatric burn inpatients.

METHODS

Admitted burn patients from 2013 to 2018 with nonsurgical management at an American Burn Association (ABA) verified pediatric burn center were retrospectively identified. Morphine milligram equivalents by weight (MME/kg) per admission were evaluated through a multiple loglinear regression with race, sex, age, total body surface area burned (TBSA), and burn depth as predictors. Simple linear regression was used to evaluate the temporal trend of median opioid utilization.

RESULTS

A total of 806 patients (55% White, 35% Black, 5% Hispanic, 5% Other) were included. In an adjusted analysis, no differences in opioid administration were seen by sex, burn degree, or for Blacks and Hispanics when compared with Whites. Increased MME/kg was associated with older age (10-18 years; p<0.0001) and larger burns (>5% TBSA burned; p<0.0001). From 2013 to 2018, median MME/kg per admission declined significantly (2013:0.21, 2018:0.09; p=0.0103).

CONCLUSIONS

Nonsurgical burn patients who were older and presented with larger TBSA experienced marked increases in opioid utilization. Overall, opioid administration decreased over time.

Pain assessment following burn injury in Australia and New Zealand: Variation in practice and its association on in-hospital outcomes

BACKGROUND

Pain is common following burn injury. Pain assessments are required to ensure appropriate pain management is provided. This study aimed to describe the prevalence and potential variation in practice of validated and documented pain assessment following burn injury in Australian and New Zealand burn units, identify clinical characteristics of patients who receive a pain assessment, and explore the associations between receiving a pain assessment and in-hospital outcomes.

METHODS

Burns Registry of Australia and New Zealand (BRANZ) admissions data were extracted. Responses to the pain assessment field were presented by contributing burns unit using frequencies and percentages. Demographic, injury severity and event, and in-hospital outcomes data were assessed.

RESULTS

There were 3009 admissions over the study period; 2481 of these received an assessment. The rate of pain assessment varied considerably between units. Women and adult patients more commonly received a pain assessment. Receiving a pain assessment was associated with a 53% adjusted increase in LOS.

CONCLUSIONS

There are differences in the profile of patients who receive a pain assessment after burn injury. The findings of this study will be reported back to designated burns units to improve pain assessment rates and patient care.

Impact of Parental Acute Psychological Distress on Young Child Pain-Related Behavior Through Differences in Parenting Behavior During Pediatric Burn Wound Care

Pediatric burn injuries and subsequent wound care can be painful and distressing for children and their parents. This study tested parenting behavior as a mediator for the relationship between parental acute psychological distress and child behavior during burn wound care. Eighty-seven parents of children (1-6-years-old) self-reported accident-related posttraumatic stress symptoms (PTSS), pre-procedural anxiety, general anxiety/depression symptoms, and guilt before the first dressing change. Parent-child behavior was observed during the first dressing change. Mediation analyses identified three indirect effects. Parental PTSS predicted more child distress, mediated through parental distress-promoting behavior. Parental guilt predicted more child distress, mediated through parental distress-promoting behavior. Parental general anxiety/depression symptoms predicted less child coping, mediated through less parental coping-promoting behavior. Parents with accident-related psychological distress have difficulty supporting their child through subsequent medical care. Nature of parental symptomology differentially influenced behavior. Increased acute psychological support for parents may reduce young child procedural pain-related distress.

A comparison of analgesia requirements in children with burns: Do delayed referrals require higher procedural analgesia doses?

Background:

Our clinical impression is that delayed referrals require more analgesia than children referred to our service acutely. Previous work demonstrated poor uptake of analgesia protocols at district hospitals with probable inadequate background and procedural analgesia, which may account for this. The purpose of this study was to compare analgesia requirements for dressing changes of paediatric patients referred to us acutely versus those children with delayed referral (i.e. more than 21 days post injury). Our hypothesis is that paediatric patients with delayed referral require higher doses of ketamine when taking length of stay and total body surface area (TBSA) of the burn into account.

Methods:

Data for children under 12 years, admitted to the Pietermaritzburg Burn Service (PBS) from the 1 July 2017 until 30 June 2018 was reviewed. Total ketamine dose during admission, weight, days admitted and TBSA were analysed. The total ketamine use in milligram per kilogram per days admitted per TBSA (mg/kg/days admitted/TBSA) was calculated. Statistical analysis was performed to compare the total ketamine dose between the acute and delayed referral groups.

Results:

One-hundred-and-ninety-seven patients were included. Patients were divided into two groups, the acute group including those referred to the PBS early (prior to 21 days post-burn) and the delayed referral group (those referred 21 days or more post burn). The acute group consisted of 167 patients and the chronic group 30 patients. There is a statistically significant difference between the total ketamine dose (mg/kg/days admitted/TBSA) for the acute referral and delayed referral groups (p = 0.01). The median total ketamine dose (mg/kg/days admitted/TBSA) of the acute referral group was 0.27 (Range: 0–7.05) and the median total Ketamine dose (mg/kg/days admitted/TBSA) for the delayed referral group was 0.41 (range: 0.1–3.89).

Conclusion:

Patients with delayed referrals require more ketamine to achieve adequate procedural analgesia than patients referred acutely. Inadequate analgesia in the acute phase of the burn may influence this, underpinning the importance of adequate analgesia right from the time of the injury.

Efficacy and cultural appropriateness of psychosocial interventions for paediatric burn patients and caregivers: a systematic review

Background

Paediatric burns are highly painful and traumatising injuries that are overrepresented among Aboriginal and Torres Strait Islander people. Paediatric burn patients’ pain remains poorly managed by pharmacological interventions, leading to increased anxiety, distress, and trauma in patients and their caregivers. Non-pharmacological psychosocial interventions have been suggested as effective in reducing pain and psychological morbidities among paediatric burn patients and their caregivers; however, their degree of effectiveness and appropriateness for Aboriginal and Torres Strait Islander people is unclear.

Methods

A non-date restricted systematic review was conducted through four databases. Studies published in English assessing psychosocial interventions on paediatric burn patients’ physical pain along with theirs and/or their caregiver’s anxiety, distress, or trauma symptoms were identified and included in this review. Included studies were assessed for their ability to reduce one of the outcomes of interests and for their reflection of Aboriginal and Torres Strait Islander peoples’ perspectives of health.

Results

Of the 3178 identified references, 17 were eligible. These include distraction based techniques (n = 8), hypnosis/familiar imagery (n = 2), therapeutic approaches (n = 4), and patient preparation/procedural control (n = 3). Distraction techniques incorporating procedural preparation reduced pain, while discharge preparation and increased ‘patient control’ reduced patient and caregiver anxiety; and internet based Cognitive Behaviour Therapy reduced short-term but not long-term post-traumatic stress symptoms. No interventions reflected Aboriginal and Torres Strait Islander peoples’ perspectives of health; and few targeted caregivers or focused on reducing their symptoms.

Conclusions

The development and assessment of psychosocial interventions to appropriately meet the needs of Aboriginal and Torres Strait Islander paediatric burn patients is required.

A Road Less Travelled: using Experience Based Co-Design to map children's and families' emotional journey following burn injury and identify service improvements

BACKGROUND

The emotional impact after a child's burn injury is poorly understood. Greater insight into the emotional journey can aid services' ability to meet patients/families' needs. To bridge the gap, this study employed an abbreviated form of Experience Based Co-Design (EBCD) to explore the emotional/experiential aspects of moderate to severe burn injuries in children.

METHOD

Following EBCD, parents and health professionals were invited to share their experiences. Interviews were analysed and a short film was produced and shown at a focus group event for health professionals and families. Both positive and negative aspects of the journey were identified along with potential service improvements.

RESULTS

Families' journeys could be described by the following five distinct phases: life overturned, dawning reality, riding the emotional roller-coaster, aftershocks and, adapting to a new normal. Key areas for improvements were: communication, isolation, dressing changes and managing expectations.

DISCUSSION

EBCD facilitated collaborative discussion between researchers, families and health professionals. Families felt empowered to shape the future of burn care and health professionals felt included. Study challenges were mainly in participant engagement and the scheduling of interviews and the focus event. Overall the study outcome was successful in generating ideas for service improvements, and the production of a training video for healthcare professionals.

Analgesia protocols for burns dressings: Challenges with implementation

BACKGROUND

The aim of this study is to compare doctors' knowledge regarding analgesia in paediatric burns patients in a setting where analgesia protocols are provided but not reinforced to a setting where the same protocols are used but with constant re-enforcement from burns surgeons.

METHODS

We reviewed questionnaires completed anonymously by doctors managing burns children in the Pietermaritzburg (PMB) Hospital Complex and the referral hospitals.

RESULTS

The questionnaire was completed by 43 doctors with 53% of the participants working in the referral hospitals. Procedural sedation was given by 98% of doctors. All PMB doctors giving procedural sedation used ketamine compared to 39% in the referral hospitals, which was statistically significant (×2 = 18.237; p < 0.001). Eighty percent of PMB doctors were aware of the correct doses of ketamine and compared to 8% of referral doctors. This was statistically significant (×2 = 21.778; p < 0.001). When assessing the adequacy of analgesia, all of the doctors from PMB used a scoring system or clinical impression. In the referral doctor group, 54% used a scoring system, 38% used the child screaming as an indicator of inadequate analgesia.

CONCLUSION

We have identified a discrepancy in knowledge between staff in an academic burn centre and those in peripheral referral hospitals. This discrepancy translates into differences in quality of burn analgesia which patients receive. Ongoing efforts must be directed towards changing the culture of district institution and strengthening attempts to standardize care across the region.

Effects of a conscious sedation dressing on pain and anxiety in pediatric burn patients

AIM

This study examined the effects of a conscious sedation dressing on pain and anxiety in pediatric patients with burns.

METHODS

This was a quasi-experimental study, using a nonequivalent control group. Using convenience sampling, the participants were assigned to two groups, an experimental group (n = 10), which comprised children who received a conscious sedation dressing, and a control group (n = 13), which comprised children who received general dressing care. To minimize the risk of contamination between the two groups, the sampling was sequentially performed.

RESULTS

The children in the experimental group showed significantly lower levels of pain (U = 3.29, d = 1.00, P = .003) and physiological responses, as evidenced by lower systolic blood pressures, diastolic blood pressures, pulse rates, and respiratory rates than the control group (systolic blood pressures: t = 5. 05, d = 1.22, P < .001; diastolic blood pressures: t = 2.12, d = 0.93, P = .046; pulse rates: t = 2.28, d = 1.00, P = .033; and respiratory rates: t = 2.47, d = 1.09, P = .022).

CONCLUSION

The application of a conscious sedation dressing may alleviate pain and anxiety for pediatric burn patients.

Parental presence or absence during paediatric burn wound care procedures

AIM

Differing views on benefits and disadvantages of parental presence during their child's wound care after burn injury leave the topic surrounded by controversies. This study aimed to describe and explain parents' experiences of their presence or absence during wound care.

METHODS

Shortly after the burn event, 22 semi-structured interviews were conducted with parents of children (0-16 years old) that underwent hospitalization in one of the three Dutch burn centers. Eighteen of these parents also participated in follow-up interviews three to six months after discharge. Interviews were analyzed using grounded theory methodology.

RESULTS

Analyses resulted in themes that were integrated into a model, summarizing key aspects of parental presence during wound care. These aspects include parental cognitions and emotions (e.g., shared distress during wound care), parental abilities and needs (e.g., controlling own emotions, being responsive, and gaining overall control) and the role of burn care professionals.

CONCLUSION

Findings emphasize the distressing nature of wound care procedures. Despite the distress, parents expressed their preference to be present. The abilities to control their own emotions and to be responsive to the child's needs were considered beneficial for both the child and the parent. Importantly, being present increased a sense of control in parents that helped them to cope with the situation. For parents not present, the professional was the intermediary to provide information about the healing process that helped parents to deal with the situation. In sum, the proposed model provides avenues for professionals to assess parents' abilities and needs on a daily basis and to adequately support the child and parent during wound care.

Development and validity of the Burns-Child Adult Medical Procedure Interaction Scale (B-CAMPIS) for young children

BACKGROUND

Young children are at increased risk of burn injury and of procedural distress during the subsequent wound care. There are currently few observational measures validated for use with young children during medical procedures. The aim of this research was to adapt the Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R) to assess parent-young child interactions during burn wound care by including nonverbal behavioral coding.

METHOD

Eighty-seven families of children (1-6years old) were recruited at their first burn dressing change. Potential behaviors were identified through a literature review, consulting health professionals, and direct observation of parents and children during burn wound care. Nonverbal behaviors were coded live, and verbal behaviors were audio recorded for later assessment.

RESULTS

Inter-coder reliability was good to excellent for the Burns-CAMPIS (B-CAMPIS). The additional behaviors were correlated with the hypothesized coping, distress, coping-promoting and distress-promoting categories of the CAMPIS-R. Some behaviors differed in frequency across child age groups, with older children demonstrating more verbal behaviors. Convergent validity was demonstrated through correlations with previously validated observational parent-child behavior measures, and parent- and nurse- reported measures of child pain and anxiety. Univariate regression analyses demonstrated the child categories of the B-CAMPIS accounted for equal or more of the variance of parent- and nurse- reported child pain and anxiety, compared to the CAMPIS-R.

CONCLUSIONS

The B-CAMPIS is a reliable and valid measure, for assessing coping and distress relationships in young children and their families. Pending further validation, the B-CAMPIS assists researchers and clinicians to recognize and target important behaviors to improve young child coping during pediatric burn wound care.

Welfare Effects of the Use of a Combination of Local Anesthesia and NSAID for Disbudding Analgesia in Dairy Calves-Reviewed Across Different Welfare Concerns

Across the international dairy industry, the vast majority of dairy herds have dehorned cows. Farmers choose to dehorn calves for different reasons such as easier handling of non-horned cattle and reduced risk of injuries in animals and staff. This review focuses on disbudding by use of hot-iron cautery as is practiced by dairy farmers in calves <3 months of age. We examine welfare effects of the use of NSAIDs in combination with a local anesthetic including indicators relevant for the three major welfare concerns-affective states, basic health, and functioning as well as the possibility to behave naturally. Across indicators of animal welfare, the majority of available evidence suggest that the use of NSAIDs in combination with a local anesthetic is advantageous in terms of animal welfare, and no studies suggest that NSAIDs are a disadvantage to animal welfare. However, irrespective of the welfare concern, use of NSAIDs combined with a local anesthetic does not fully eliminate the welfare challenges from disbudding. Further research is needed in order to fully understand the effects of this medication protocol on calf welfare, including knowledge about the duration of healing and the presence of long-term pain. At present, this lack of knowledge challenges the precise formulation of adequate pain management-in terms of medication protocol, duration, dosage, and type of administration.

Considerations for pediatric burn sedation and analgesia

Burn patients experience anxiety and pain in the course of their injury, treatment, and recovery. Hence, treatment of anxiety and pain is paramount after burn injury. Children, in particular, pose challenges in anxiety and pain management due to their unique physiologic, psychologic, and anatomic status. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. Burn injuries further complicate pain management and sedation as such injuries can have effects on medication response and elimination. The purpose of this review is to describe the challenges associated with management of anxiety, pain, and sedation in burned children and to describe the different options for treatment of anxiety and pain in burned children.

Burn Care in Low- and Middle-Income Countries

This article examines the societal impact of thermal injury in low- and middle-income countries. The authors describe the unique challenges of these health care systems in providing care for burned patients, focusing on resuscitation, excision and grafting, rehabilitation, and reconstruction.

Dressing changes in a burns unit for children under the age of five: A qualitative study of mothers' experiences

This study aimed to investigate the experiences of mothers who had attended their child's burn dressing changes. Participants were recruited from a burns unit based within a children's hospital. Face-to-face interviews were conducted with five mothers of children under the age of five who had undergone a series of dressing changes taking place on the burns unit. The interview guide explored parents' experience of initial and subsequent dressing changes. Participants were prompted to explore their expectations, thoughts, feelings and behaviours associated with these experiences. The interviews were recorded and transcribed verbatim. Transcripts were analysed using interpretative phenomenological analysis. The analysis identified four themes: 'needing to fulfil the responsibilities associated with being a mother'; 'emotional synchrony between mother and child'; 'being informed and knowing what to expect'; and 'the importance of establishing rapport with nurses performing dressing changes'. Findings from this research can inform services to help optimise mothers' experiences of dressing changes in this stage of pediatric burn care.

Nursing management of children's pain: Current evidence and future directions for research

This critical literature review discusses the research evidence underpinning each of the pain standards in the National Service Framework for Children: Standard for hospital services. Relevant evidence-based reviews and clinical practice guidelines are highlighted, and aspects of children's pain management where the research evidence is particularly strong or weak are identified. Priorities are suggested for nurse-led research aimed at generating new knowledge to improve pain management for children.

Posttraumatic Stress Disorder in the Child of an Adult Burn Victim: A Case Report and Review of the Literature

Adults with a myriad of medical and surgical conditions are at risk for pain, delirium, and disfigurement. Needless to say, these critical illnesses are profoundly stressful for patients and their caregivers. However, physicians rarely consider the reactions of children to their parents’ illnesses. The article presents the case of a 15-year-old girl who developed posttraumatic stress disorder following her mother’s severe burn and complicated course in a critical care unit; the case is used to discuss strategies for the detection of psychological vulnerability and for the implementation of care. By learning more about the children of adult patients, by screening for interpersonal dysfunction, and by maximizing support systems, clinicians can improve function and minimize distress.

Effectiveness of medical hypnosis for pain reduction and faster wound healing in pediatric acute burn injury: study protocol for a randomized controlled trial

BACKGROUND

Burns and the associated wound care procedures can be extremely painful and anxiety-provoking for children. Burn injured children and adolescents are therefore at greater risk of experiencing a range of psychological reactions, in particular posttraumatic stress disorder, which can persist for months to years after the injury. Non-pharmacological intervention is critical for comprehensive pain and anxiety management and is used alongside pharmacological analgesia and anxiolysis. However, effective non-pharmacological pain and anxiety management during pediatric burn procedures is an area still needing improvement. Medical hypnosis has received support as a technique for effectively decreasing pain and anxiety levels in adults undergoing burn wound care and in children during a variety of painful medical procedures (e.g., bone marrow aspirations, lumbar punctures, voiding cystourethrograms, and post-surgical pain). Pain reduction during burn wound care procedures is linked with improved wound healing rates. To date, no randomized controlled trials have investigated the use of medical hypnosis in pediatric burn populations. Therefore this study aims to determine if medical hypnosis decreases pain, anxiety, and biological stress markers during wound care procedures; improves wound healing times; and decreases rates of traumatic stress reactions in pediatric burn patients.

METHODS/DESIGN

This is a single-center, superiority, parallel-group, prospective randomized controlled trial. Children (4 to 16 years, inclusive) with acute burn injuries presenting for their first dressing application or change are randomly assigned to either the (1) intervention group (medical hypnosis) or (2) control group (standard care). A minimum of 33 participants are recruited for each treatment group. Repeated measures of pain, anxiety, stress, and wound healing are taken at every dressing change until ≥95 % wound re-epithelialization. Further data collection assesses impact on posttraumatic stress symptomatology, speed of wound healing, and parent perception of how easy the dressing change is for their child.

DISCUSSION

Study results will elucidate whether the disease process can be changed by using medical hypnosis with children to decrease pain, anxiety, and stress in the context of acute burn wounds.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615000419561.

Pain and the thermally injured patient-a review of current therapies

Thermally injured patients experience tremendous pain from the moment of injury to months or years after their discharge from the hospital. Pain is therefore a critical component of proper management of burns. Although the importance of pain is well recognized, it is often undertreated. Acute uncontrolled pain has been shown to increase the incidence of mental health disorders and increase the incidence of suicide after discharge. Long-term poor pain control leads to an increase in the incidence of persistent pain. Most burn centers have used opioids as the mainstay analgesic, but recently, the significant side effects of opioids have led to the implementation of new and combined therapeutics. Pharmacological agents such as gabapentin, clonidine, dexmedetomidine, and ketamine have all been suggested as adjuncts to opioids in the treatment of burn pain. Nonpharmacological therapies such as hypnosis, virtual reality devices, and behavioral therapy are also essential adjuncts to current medications. This review aims at identifying the currently available pharmacological and nonpharmacological options for optimal pain management in the adult burn population.

Management of pediatric skin-graft donor sites: a randomized controlled trial of three wound care products

Skin grafts are used to treat many types of skin defects in children, including burns, traumatic wounds, and revision of scars. The objective of this prospective randomized controlled trial was to compare the effectiveness of three dressing types for pediatric donor sites: foam, hydrofiber, and calcium alginate. Children attending a pediatric Burns & Plastics Service from October 2010 to March 2013, who required a split-skin graft, were recruited to the trial. Patients were randomly assigned to the two experimental groups, foam or hydrofiber, and to the control group, calcium alginate. Data were gathered on the management of exudate, assessment of pain, time to healing, and infection. Fifty-seven children aged 1 to 16 years (mean = 4.9 years) were recruited to the trial. Fifty-six patients had evaluable data and one participant from the control group was lost to follow-up. Most children required skin grafting for a burn injury (78%). The median size of the donor site was 63.50 cm (8-600 cm). There was a statistically significant difference in time to healing across the three dressing groups (x [2, n = 56] = 6.59, P = .037). The calcium alginate group recorded a lower median value of days to healing (median = 7.5 days) compared to the other two groups, which recorded median values of 8 days (hydrofiber) and 9.5 days (foam). The greatest leakage of exudate, regardless of dressing type, occurred on day 2 after grafting. No statistically significant difference was found in leakage of exudate, pain scores, or infection rates across the three groups. Calcium alginate emerged as the optimum dressing for pediatric donor site healing in this trial.

Low-Dose Ketamine Infusion for Emergency Department Patients with Severe Pain

OBJECTIVE

Use of low-dose ketamine infusions in the emergency department (ED) has not previously been described, despite routine use in perioperative and other settings. Our hypothesis was that a low-dose ketamine bolus followed by continuous infusion would 1) provide clinically significant and sustained pain relief; 2) be well tolerated; and 3) be feasible in the ED.

METHODS

We prospectively administered 15 mg intravenous ketamine followed immediately by continuous ketamine infusion at 20 mg/h for 1 hour. Optional morphine (4 mg) was offered at 20, 40, and 60 minutes. Pain intensity, vitals signs, level of sedation, and adverse reactions were assessed for 120 minutes.

RESULTS

A total of 38 patients were included with a median initial numerical rating scale (NRS) pain score of 9. At 10 minutes, the median reduction in pain score was 4, with 7 patients reporting a score of 0. At 60 and 120 minutes, 25 and 26 patients, respectively, reported clinically significant pain reduction (decrease NRS score > 3). Heart rate, blood pressure, respiratory rate, and oxygen saturation remained stable. Mild or moderate side effects including dizziness, fatigue, and headache were common. Patient satisfaction was high; 85% reported they would have this medication again for similar pain.

CONCLUSION

A low-dose ketamine infusion protocol provided significant pain relief with mostly mild side effects and no severe adverse events.

Acute and perioperative care of the burn-injured patient

Care of burn-injured patients requires knowledge of the pathophysiologic changes affecting virtually all organs from the onset of injury until wounds are healed. Massive airway and/or lung edema can occur rapidly and unpredictably after burn and/or inhalation injury. Hemodynamics in the early phase of severe burn injury is characterized by a reduction in cardiac output and increased systemic and pulmonary vascular resistance. Approximately 2 to 5 days after major burn injury, a hyperdynamic and hypermetabolic state develops. Electrical burns result in morbidity much higher than expected based on burn size alone. Formulae for fluid resuscitation should serve only as guideline; fluids should be titrated to physiologic endpoints. Burn injury is associated basal and procedural pain requiring higher than normal opioid and sedative doses. Operating room concerns for the burn-injured patient include airway abnormalities, impaired lung function, vascular access, deceptively large and rapid blood loss, hypothermia, and altered pharmacology.

Interactive effects of acupuncture on pain and distress in major burns: An experiment with rats

This study sought to investigate the interactive effects of acupuncture on pain and distress and the local progress in the burn wound in an experimental major burn model. Forty-eight male Sprague-Dawley rats were divided into six groups: S group (sham/observation during 7 days after injury); SA group (sham/acupuncture/observation during 7 days after injury); B1 group (burns/observation during 1h after injury); BA1 group (burns/acupuncture/observation during 1 h after injury); B7 group (burns/observation during 7 days after injury); and BA7 group (burns/acupuncture/observation during 7 days after injury). Pain and distress scores were evaluated throughout the study. The amounts of neutrophils and mononuclear cells were evaluated semiquantitatively, and the number of microvessels was evaluated quantitatively. Our data indicated that the average pain score of BA7 group was significantly lower than the other study groups. Histopathologic investigations indicate that the amounts of neutrophil and mononuclear cell and numbers of microvessels in the unburned skin were higher in acupuncture-applied groups. The number of microvessels in burn wounds of BA7 group was significantly higher than that of the other groups. Our data suggest that acupuncture provides low pain and distress scores in experimental rat model, and it contributes to wound healing with an enhanced angiogenesis during the acute phase of burns. Future clinical and experimental studies should be conducted to discern the benefits from acupuncture in pain management of burn patients.

Acute pain management in burn patients: appraisal and thematic analysis of four clinical guidelines

OBJECTIVE

Burn patients suffer excruciating pain due to their injuries and procedures related to surgery, wound care, and mobilization. Acute Stress Disorder, Post-Traumatic Stress Disorder, chronic pain and depression are highly prevalent among survivors of severe burns. Evidence-based pain management addresses and alleviates these complications. The aim of our study was to compare clinical guidelines for pain management in burn patients in selected European and non-European countries. We included pediatric guidelines due to the high rate of children in burn units.

METHOD

The study had a comparative retrospective design using combined methodology of instrument appraisal and thematic analysis. Three investigators appraised guidelines from burn units in Denmark (DK), Sweden (SE), New Zealand (NZ), and USA using the AGREE Instrument (Appraisal of Guidelines for Research & Evaluation), version II, and identified core themes in the guidelines.

RESULTS

The overall scores expressing quality in six domains of the AGREE instrument were variable at 22% (DK), 44% (SE), 100% (NZ), and 78% (USA). The guidelines from NZ and USA were highly recommended, the Swedish was recommended, whereas the Danish was not recommended. The identified core themes were: continuous pain, procedural pain, postoperative pain, pain assessment, anxiety, and non-pharmacological interventions.

CONCLUSION

The study demonstrated variability in quality, transparency, and core content in clinical guidelines on pain management in burn patients. The most highly recommended guidelines provided clear and accurate recommendations for the nursing and medical staff on pain management in burn patients. We recommend the use of a validated appraisal tool such as the AGREE instrument to provide more consistent and evidence-based care to burn patients in the clinic, to unify guideline construction, and to enable interdepartmental comparison of treatment and outcomes.

A comparative study of paediatric thermal burns treated with topical heparin and without heparin

Following reports of heparin use in burn treatment, an ethics-committee-approved prospective randomized study with controls compared results obtained using traditional usual burn treatment without heparin with results in similar patients similarly treated with heparin added topically. The subjects were 100 consecutive burn patients (age <15 years) with second-degree superficial and deep burns of 5-45 % total body surface area size. Two largely similar cohort groups-a control group (C) and a heparin group (H) with 50 subjects per group-were randomly treated. The 50 control group patients received traditional routine treatment, including topical antimicrobial cream, debridement, and, when needed, skin grafts in the early postburn period. The 50 heparin group patients, without topical cream, were additionally treated, starting on day 1 postburn, with 200 IU/ml sodium aqueous heparin solution USP (heparin) dripped on the burn surfaces and inserted into the blisters two to four times a day for 1-2 days, and then only on burn surfaces for a total of 5-7 days, before skin grafting, when needed. Thereafter, control and heparin group treatment was similar. It was found that the heparin patients complained of less pain and received less pain medicine than the control patients. The heparin group needed fewer dressings and oral antibiotics than the control group. The 50 heparin group patients had 4 skin graftings (8 %), while the 50 control group patients had 10 (20 %). Five control group patients died (mortality 10 %). No heparin group patients died. The number of days in hospital for the heparin group versus control group was significantly less (overall P < 0.0001): 58 % of heparin group patients were discharged within 10 days versus 6 % of control group patients; 82 % of heparin group patients were out in 20 days versus 14 % of control group patients; 98 % of the heparin group versus 44 % of the control group were out in 30 days; and while 100 % of heparin group patients were discharged by day 40, 56 % of the control group required up to another 10 days. Burns in heparin group patients healed on average in 15 days (maximum period 37 days) versus an average of 25 days (maximum >48 days) in control group patients (P < 0.0006). Procedures and costs in the heparin group were much reduced compared with the control group. Differences between the heparin and control groups are presented for the sake of comparison. It was concluded that heparin applied topically for 5-7 days improved burn treatment: it reduced pain, pain medicine, dressings, and use of antibiotics; it significantly reduced IV fluids (P < 0.04), days in hospital (P < 0.0001), and healing time (P < 0.0006); and it reduced skin grafts, mortality, and costs.

Management of Traumatic Wounds and a Novel Approach to Delivering Wound Care in Children

Significance: The costs and morbidity of pediatric traumatic wounds are not well known. The literature lacks a comprehensive review of the volume, management, and outcomes of children sustaining soft tissue injury. We briefly review the existing literature for traumatic wounds such as open fractures and burns. Such injuries require dedicated wound care and we propose a novel approach for more efficient and more effective delivery of dedicated pediatric wound care. Recent Advances: New pediatric literature is emerging regarding the long-term effects of wound care pain in traumatic injuries-especially burns. A variety of wound dressings and alternative management techniques exist and are geared toward reducing wound care pain. Our institution utilizes a unique model to provide adequate sedation and pain control through a dedicated pediatric wound care unit. We believe that this model reduces the cost of wound care by decreasing emergency department and operating room visits as well as hospital length of stay. Critical Issues: First, medical costs related to pediatric traumatic wound care are not insignificant. The need for adequate pain control and sedation in children with complex wounds is traditionally managed with operating room intervention. Afterward, added costs can be from a hospital stay for ongoing acute wound management. Second, morbidities of complex traumatic wounds are shown to be related to the acute wound care received. Future Directions: Further guidelines are needed to determine the most effective and efficient care of complex traumatic soft tissue injuries in the pediatric population.

Pain in young children with burns: extent, course and influencing factors

Little evidence is available on the extent, course and influencing factors of pain in young children with burns. At present, reliable and valid measurement instruments to assess pain behavior in these children are available, implying that valuable insight into these questions can now be obtained. The aim of this study is to document the extent and course of pain behavior with the COMFORT-B, and to assess factors that may influence procedural pain. First, cutpoints for COMFORT-B scores were established by Rasch analysis to assess clinically relevant changes. Second, the extent of background and procedural pain behavior was assessed by descriptive statistics. Third, the course and factors that may influence procedural pain behavior were investigated by latent growth modeling. Trained nurses collected pain behavior data in 168 children (mean age 20 months, mean TBSA 6%, mean length of stay 10 days). Cutpoints of COMFORT-B scores were as follows: 6-13 (mild pain), 14-20 (moderate pain) and 21-30 (severe pain). This study suggests that background pain is more adequately treated than procedural pain. Factors that influenced baseline pain scores and/or the course over 8 days included TBSA, the number of surgical procedures, acetaminophen administration by the referring hospital, and the application of hydrofiber dressings. The implications of these findings are discussed.

Hemodynamic responses to dexmedetomidine in critically injured intubated pediatric burned patients: a preliminary study

Because of ineffectiveness and tolerance to benzodiazepines and opioids developing with time, drugs acting via other receptor systems (eg, α-2 agonists) have been advocated in burn patients to improve sedation and analgesia. This study in severely burned pediatric subjects examined the hemodynamic consequences of dexmedetomidine (Dex) administration. Eight intubated patients with ≥20 to 79% TBSA burns were studied between 7 and 35 days after injury. After baseline measurements of mean arterial blood pressure and heart rhythm were taken, each patient received a 1.0 µg/kg bolus of Dex followed by an ascending dose infusion protocol (0.7-2.5 µg/kg/hr), with each dose administered for 15 minutes. There was significant hypotension (27±7.5%, average drop in mean arterial pressure [MAP] ± SD), and a decrease in heart rate (HR; 19% ± 7, average drop in HR ± SD). The average HR decreased from 146 beats per minute to 120. No bradycardia (HR < 60) or heart blocks were observed. In three patients, the MAP decreased to <50mm Hg with the bolus dose of Dex. Of the remaining five patients, three patients completed the study receiving the highest infusion dose of Dex (2.5 µg/kg/hr), whereas in 2 patients the infusion part of the study was begun, but the study was stopped due to persistent hypotension (MAP < 50mm Hg). These observations indicate that a bolus dose of Dex (1.0 µg/kg for 10 minutes) and high infusion rates may require fluid resuscitation or vasopressor support to maintain normotension in critically injured pediatric burn patients.

Pediatric burn rehabilitation: Philosophy and strategies

Burn injuries are a huge public health issue for children throughout the world, with the majority occurring in developing countries. Burn injuries can leave a pediatric patient with severely debilitating and deforming contractures, which can lead to significant disability when left untreated. Rehabilitation is an essential and integral part of pediatric burn treatment. The aim of this article was to review the literature on pediatric burn rehabilitation from the Medline, CINAHL, and Web of Science databases. An attempt has been made to present the basic aspects of burn rehabilitation, provide practical information, and discuss the goals and conceptualization of rehabilitation as well as the development of rehabilitation philosophy and strategies.

Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain

OBJECTIVE

We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain.

METHODS

This was a prospective observational study of adult patients with severe pain at an urban public hospital. We administered 0.5 mg of intravenous (IV) hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120 minutes using a 10-point verbal numerical rating scale (NRS). Patients were monitored throughout for adverse events. Dissociative side effects were assessed using the side effects rating scale for dissociative anesthetics.

RESULTS

Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9), 14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain score was 5.0 (SD, 2.8). The summed pain intensity difference and percent summed pain intensity difference scores were 25 (95% confidence interval [CI], 21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50% (95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only weak or modest side effects. Ninety percent of patients reported that they would have the medications again. No significant adverse events occurred.

CONCLUSIONS

Low-dose ketamine combined with a reduced dose hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain.

Oral ketamine and midazolam for pediatric burn patients: a prospective, randomized, double-blind study

PURPOSE

The aim of this study was to compare the efficacy of oral midazolam and ketamine with oral midazolam, acetaminophen, and codeine in providing sedation and analgesia for wound care procedures in children with burns.

METHODS

This is a prospective, randomized, double-blind study that includes patients 1 to 5 years old hospitalized between 2010 and 2011, with burns covering up to 10% of total body surface area that required bedside wound care. Group 1 received oral midazolam (0.5mg/kg) and ketamine (5mg/ kg). Group 2 received oral midazolam (0.5mg/kg), acetaminophen (10mg/kg), and codeine (1mg/kg). Sedation was assessed using the University of Michigan Sedation Scale and pain using the CHEOPS scale.

RESULTS

Sixty patients were enrolled and evenly distributed into the two groups. There were a higher percentage of well-sedated patients in Group 1, but this was not statistically significant. Patients in Group 2 reported lower levels of pain (p=0.0245). Adverse reactions were reported in both groups. The only parameter that had a statistical difference was nystagmus (p=0.001).

CONCLUSION

The combination of oral midazolam and ketamine provides better analgesia than the combination of midazolam, acetaminophen, and codeine for painful procedures in burned children.

Equipe de saúde e o brincar da criança com queimaduras

A pesquisa objetivou analisar as percepções da equipe de saúde sobre o brincar da criança hospitalizada com queimaduras. Participaram da amostra 30 profissionais de saúde da Unidade de Tratamento de Queimados. Utilizou-se um questionário, e a análise destacou que a equipe de saúde considera relevante o brincar no hospital devido às contribuições para a adesão ao tratamento, evolução clínica, adaptação e interação social da criança com queimaduras. Na perspectiva desses profissionais, o brincar por meio da função terapêutica permite que a criança hospitalizada desenvolva a criatividade, enfrente a dor, e utilize o manejo nas situações de estresse, o que possibilita auxiliar o processo de recuperação da saúde integral. Os dados positivos evidenciam a importância do brincar para a criança na situação de doença e hospitalização.

Pediatric burn injuries

Pediatric burns comprise a major mechanism of injury, affecting millions of children worldwide, with causes including scald injury, fire injury, and child abuse. Burn injuries tend to be classified based on the total body surface area involved and the depth of injury. Large burn injuries have multisystemic manifestations, including injuries to all major organ systems, requiring close supportive and therapeutic measures. Management of burn injuries requires intensive medical therapy for multi-organ dysfunction/failure, and aggressive surgical therapy to prevent sepsis and secondary complications. In addition, pain management throughout this period is vital. Specialized burn centers, which care for these patients with multidisciplinary teams, may be the best places to treat children with major thermal injuries. This review highlights the major components of burn care, stressing the pathophysiologic consequences of burn injury, circulatory and respiratory care, surgical management, and pain management of these often critically ill patients.

A randomized controlled trial of sertraline to prevent posttraumatic stress disorder in burned children

BACKGROUND

This study evaluated the potential benefits of a centrally acting selective serotonin reuptake inhibitor, sertraline, versus placebo for prevention of symptoms of posttraumatic stress disorder (PTSD) and depression in burned children. This is the first controlled investigation based on our review of the early use of a medication to prevent PTSD in children.

METHODS

Twenty-six children aged 6-20 were assessed in a 24-week double-blind placebo-controlled design. Each child received either flexibly dosed sertraline between 25-150 mg/day or placebo. At each reassessment, information was collected in compliance with the study medication, parental assessment of the child's symptomatology and functioning, and the child's self-report of symptomatology. The protocol was approved by the Human Studies Committees of Massachusetts General Hospital and Shriners Hospitals for Children.

RESULTS

The final sample was 17 subjects who received sertraline versus 9 placebo control subjects matched for age, severity of injury, and type of hospitalization. There was no significant difference in change from baseline with child-reported symptoms; however, the sertraline group demonstrated a greater decrease in parent-reported symptoms over 8 weeks (-4.1 vs. -0.5, p=0.005), over 12 weeks (-4.4 vs. -1.2, p=.008), and over 24 weeks (-4.0 vs. -0.2, p=0.017).

CONCLUSIONS

Sertraline was a safe drug, and it was somewhat more effective in preventing PTSD symptoms than placebo according to parent report but not child report. Based on this study, sertraline may prevent the emergence of PTSD symptoms in children.

Analgesia and sedation for children undergoing burn wound care

Standard care of burn wounds consists of cleaning and debridement (removing devitalized tissue), followed by daily dressing changes. Children with burns undergo multiple, painful and anxiety-provoking procedures during wound care and rehabilitation. The goal of procedural sedation is safe and efficacious management of pain and emotional distress, requiring a careful and systematic approach. Achieving the best results needs understanding of the mechanisms of pain and the physiologic changes in burn patients, frequent evaluation and assessment of pain and anxiety, and administration of suitable pharmacological and nonpharmacological therapies. Pharmacological therapies provide the backbone of analgesia and sedation for procedural pain management. Opioids provide excellent pain control, but they must be administered judiciously due to their side effects. Sedative drugs, such as benzodiazepines and propofol, provide excellent sedation, but they must not be used as a substitute for analgesic drugs. Ketamine is increasingly used for analgesia and sedation in children as a single agent or an adjuvant. Nonpharmacological therapies such as virtual reality, relaxation, cartoon viewing, music, massage and hypnosis are necessary components of procedural sedation and analgesia for children. These can be combined with pharmacological techniques and are used to limit the use of drugs (and hence side effects), as well as to improve patient participation and satisfaction. In this article, we review the pathophysiologic changes associated with major thermal injury in children, the options available for sedation and analgesia for wound care procedures in these children and our institutional guidelines for procedural sedation.